Tuesday, April 21, 2015

Six Steps to Managing ADHD Overload

guest blog by Mark Bertin, MD

When the logistical details of life and school accumulate, they become overwhelming for students with ADHD. If they have weak executive function skills, they will require ongoing support from an adult.

What steps can you take to help children and teens with ADHD learn to manage the academic demands that increase as they grow older? And if your child falls behind and must somehow weather an academic storm, what strategies can change the situation and teach him or her to better manage ADHD challenges?

1. Clear the decks. When needed, hit the reset button. Forge a one-time amnesty, forgive the backlog, and begin from scratch. If someone is not yet able to do what is being asked every day, there is not much chance they are going to keep up plus catch up. If amnesty is not entirely possible, at minimum we distribute the backlog over time so that the total work required every day is sustainable. The goal is maintaining a reasonable amount of work each day, within what is possible for any individual.

Kids should not expect this type of amnesty to be constantly available. However, “responsibility” and “motivation” only follow from success, and success stems from asking kids to work within their actual ability level. Homework isn’t meant to bring to mind Sisyphus pushing his boulder up the hill, never to quite reach the top before it rolls down again. If a child can get five things done each day and we keep asking for six, eventually the child will fall behind.

2. Establish a daily plan. Create a detailed and easy-to-follow daily checklist. Setting and sustaining a plan to manage homework is not intuitive to most children with ADHD. Knowing when to get started, predicting time, keeping track of books and assignments, and many related skills are all related to executive functions. Parents should set a homework time and create a distraction-free place to get things done. If the after-school schedule varies, instead of a specific time the rule might be “work starts fifteen minutes after getting home.”

Most students benefit from a step-by-step, written checklist for how to complete work appropriately. To make certain things get back to school, include a clear ending such as “put your homework away in your homework folder.” While working, children also often find it easier to focus with scheduled stretches on task interspersed with timed breaks (such as twenty minutes on, five minutes off). In-school supports involve breaking down assignments into daily parts, checking out with a teacher at the end of the day, reminders to hand in work to the teacher, and countless other possibilities (see the CHADD Educator Manual for more).

Monitor the child's development. A ten year old might have the skills of a six year old when it comes to organization. Unfortunately, there is no one perfect measure of executive function in real life, so observe, make informed choices, and readjust based on how a child progresses.

Maybe the child is not ready to manage his or her own to-do list at school. Maybe he cannot yet see how to break a longer project into its component parts. Maybe initiating her work after school is hard, or prioritizing time, or estimating how long various assignments will take each night. All these difficulties require direct support and instruction. By sustaining a daily routine over months or years of school, it becomes a habit all the way through adulthood.

3. Externalize the system. Maintain adult support and involvement. Getting off task from a long-term plan is a routine part of ADHD, and does not typically stem from poor effort or laziness. Identify a parent, teacher, therapist, ADHD coach, or anyone else who can make sure the details are being followed. While written checklists and physical alarms also can act as external reminders, children need someone supervising with higher-level organizational skills.

A solid solution often involves parents and teachers almost taking over organization in the short run. Temporary relief from responsibilities allows more energy for learning and keeping up with the more methodical plan you’ve created. A long-term plan hands back responsibility at whatever pace a student proves capable.

4. Consider modified homework. Avoid the counterproductive punishment of adding more to an already daunting load. In Understand Your Brain, Get More Done: The ADHD Executive Function Workbook (Specialty Press, 2012), psychologist Ari Tuckman writes, “It is vital to keep up with work as it comes—because it becomes impossible to do it all at the end. Homework can sometimes be (or feel like) a losing battle where it is impossible to keep up at all. At those times it may be helpful to speak about homework reductions, especially when a student is spending a lot of time but not getting enough done.”

ADHD isn't an excuse for slacking off. Children with ADHD should show good effort and do what is needed to learn. But they also should not spend their whole lives treading water, up to their necks in schoolwork. The goal is to find a groove where a child works hard but does not get consumed. Homework is meant to augment classroom academics. While the research is vague, the recommendation is around ten minutes per grade.

5. Offer stress management tools. A first step to managing stress may simply be managing ADHD itself. ADHD compounds stress by making it hard to get anything done all day long. With ADHD, every detail may be taking ten times the effort with five times the uncertainty. Assertive management supports long-term success by balancing behavioral, educational, medical, and even complementary options when appropriate.

Stress itself makes managing ADHD difficult. Under stress, most of us fall back on old habits, become more reactive, and lose our resilience. For an individual or family living with ADHD, these patterns make it harder to keep up with any plan. Working with a behavioral therapist or ADHD coach may help both in addressing executive function deficits and in developing stress management tools. The practice of mindfulness is also an evidence-backed, accessible way to manage stress.

6. Create an early warning system. Schools should contact families as soon as assignments are missed. Finding out about seven missed homework assignments over two months is hard to address, but finding out about two over a week is manageable. Don’t allow the back-up to happen in the first place.

If work starts accumulating, step back and look at the bigger picture: Can the child do the work asked of him? Has he had an appropriate educational evaluation? At least half of children with ADHD also have a learning disability and others have language delays. Assigned homework should consider present academic abilities and avoid material above a student’s ability level.

When the student continues to miss assignments, consider whether he or she is able to handle the workload right now. Does the child need more directed organizational supports? Modifications that cut back on the amount required each night? Does medication need adjusting? Is homework even being done during the window of time medication covers?

THROUGH THE COMBINATION of an external system, adult monitoring, and modification of work, school and homework should become more manageable. As the system become more ingrained, most students with ADHD can handle a workload similar to that of their peers.

A slow drip of missed details can affect anything your child must keep up with in life, but the same technique applies. Emails pile up; the solution balances getting the in-box back to zero and creating a plan to keep up every day. If the child has an astoundingly messy room, start with a one-time effort to put everything in place while in tandem establishing a new system of some kind — maybe ten minutes of cleaning before bedtime. Balancing short-term exertion with a realistic and empathetic long-term plan creates an entirely new way of living with ADHD.

A longer version of this post appeared in the June 2013 issue of Attention magazine. Join CHADD and receive every issue!
Join conversations about parenting kids with ADHD on Attention connection, your social network for all things ADHD!

Mark Bertin, MD, is a pioneering developmental pediatrician in private practice in Pleasantville, New York, and assistant professor of pediatrics at New York Medical College. He trains physicians, teachers, and psychologists in ADHD care and leads stress-reduction classes for parents. From 2003 to 2010, he was director of developmental pediatrics at the Westchester Institute for Human Development. He is the author of The Family ADHD Solution (Macmillan, 2011).

Tuesday, April 14, 2015

ADHD and Organizational Overload

by Mark Bertin, MD

Imagine that you are in ninth grade and you are given six assignments a day to complete. That’s a gross simplification over real life, which requires you to figure out when to do the work, how to do it, to coordinate various long-term projects, and to manage your busy life in general. But for now, imagine you need do nothing more than get those six things done... except you have ADHD and because of that you’re only capable of completing five.

Far from a disorder of only attention or hyperactivity, ADHD represents a neurologically programmed deficit in the exact managerial skills that allow you to handle everyday logistics effectively. So you continue to work diligently, even though people implore you to try even harder. By day two you have six more assignments plus one to make up from day one. By the end of the week, you’re potentially five assignments behind. By the end of the first month, you may be dozens of items behind—and now demands have risen to seven assignments a day. Whatever can you do?

An unexpected academic squall

There’s only so much any of us can accomplish in any one day. For someone with ADHD, that amount often shrinks compared to other people, since ADHD undermines cognitive abilities called “executive functions” that are required for planning, organizing, managing time, and prioritizing. So, where one person may be able to juggle a pressured high school academic schedule, two sports, and a social life, someone with ADHD may have used up their cognitive resources by noon.

Sometimes what had been a reasonable organizational plan no longer holds together as demands rise over time. Maybe before high school, not having a consistent to-do list or some type of logical plan to manage long-term projects was okay; not ideal, but manageable, and the procrastination did not impact life too much yet. By high school, there’s too much to mentally track and better time management becomes essential.

Each little bit not quite accomplished throughout the day rolls over to the grand life to-do list. It accumulates into an overwhelming and insurmountable pile, until eventually the whole system shuts down. A child with barely the bandwidth to keep up now is asked to make up an additional pile of missed assignments. Their cognitive gears lock when the combination of both doing their everyday work and their overdue list becomes literally too much to handle.

Stress is often defined as the perception that something in life is not manageable. The sense that the load has become impossible creates stress, which further undermines efficiency. Things fall apart—perhaps they stop working entirely. For some, it can even become “learned helplessness,” the assumption after repeated failure that there is no point to trying again. School anxiety grows and children may lie about their work, make excuses, or become oppositional in avoiding it. The solution lies in creating realistic daily demands that account for ADHD and implementing a structured organizational system that allows someone to maintain day-to-day control.

Take the rudder and hold on tight

Problem solving can be challenging even for a motivated child with ADHD. The executive function skills needed to identify the root of an issue, create a strategy, and stick to the organization system over time are all impaired. So instead of being able to pause, gather himself, and refocus as we might hope, the wheels come off entirely. He creates a plan that isn’t sustainable (I’ll stay up three hours later every night until I’m all caught up) or is inefficient to the point of increasing overall effort and stress.

To create a solution, we instead aim to “externalize the system”—when executive function is impaired, we build an external structure that supports it. Mental managerial skills are replicated through routines and reminders until they become more habitual. Thankfully, many tools support organization, ranging from day planners to sophisticated, smart-phone applications. This approach seems intuitive if you have strong executive function skills, but can be inherently difficult when you have ADHD.

Critical to implementing a new framework is recognizing the need for ongoing support from an adult. It does not quite make sense to expect someone to monitor a plan on their own if their core impairment is an inability to organize their life. Maintaining a compassionate perspective means recognizing that however it looks from the outside, the underlying issue is not effort or motivation but a developmental delay in executive function. In many ways, having ADHD undermines the exact skill set needed to start addressing ADHD in the first place.

Next week we'll look at strategies for managing ADHD overload.

A longer version of this post appeared in the June 2013 issue of
Attention magazine. Join CHADD and receive every issue!
Join conversations about parenting kids with ADHD on Attention connection, your social network for all things ADHD!

Mark Bertin, MD, is a pioneering developmental pediatrician in private practice in Pleasantville, New York, and assistant professor of pediatrics at New York Medical College. He trains physicians, teachers, and psychologists in ADHD care and leads stress-reduction classes for parents. From 2003 to 2010, he was director of developmental pediatrics at the Westchester Institute for Human Development. He is the author of The Family ADHD Solution (Macmillan, 2011).

Tuesday, April 7, 2015

More Magic of Pet Ownership, Part Two

by Elaine Taylor-Klaus, CPCC, PCC

Part one of this post described two good reasons to include a pet in your family. Here are three more reasons pet ownership can be a helpful support strategy for ADHD.

Structure and accountability

Not only can kids cultivate relationships with pets, but they can learn to put systems and structures in place to care for them. Since kids with ADHD often have a difficult time finding the motivation to accomplish “boring” tasks, a pet offers the chance to make a household chore more “interesting.” Let’s be serious — feeding the dog is at least more compelling than washing the dishes!

In our home, our youngest child is expected to feed the dog before he feeds himself, twice a day. While our son is not yet completely independent in this task, it has provided a platform to teach him to set up systems, tweak them, and re-establish them as needed.

For example, recently we noticed our son had become a bit slack on remembering to feed the dog before himself. (This is common in ADHD world when systems become “boring” and difficult to continue). Keeping a note at his place at the table was no longer working, so we brainstormed about how he could make sure he handled this task. (As if on cue, the dog looked up at him with soft brown eyes and tilted her head as if to say, “What about me?” It was perfect!)

Our son decided to draw a picture of a dog to keep at his place at the table as a reminder, along with a really funny Valentine’s Day card he'd gotten from her. It’s too soon to say if it will work, but having to address this every so often is actually a great opportunity. It teaches him that his ADHD requires constant vigilance.

By learning to care for his dog—with a parental safety net so the dog doesn’t go hungry—our son is learning critical lessons about how his ADHD shows up, and what he’s going to need to do to manage it in his life.

Managing impulsivity

As pet owners, we can’t afford to forget, for a moment, that our animals are just that—domesticated, maybe, but animals nonetheless. A girl and her dog can have the most wondrous relationship imaginable, but it is inherently dangerous. Success comes when you create a conscious environment and keep a safety mindset.

At one point, I had my doubts. There was a particular episode in Sasha’s youth when I was afraid we had made a big mistake. She had discovered a Brillo pad under the house and appeared with it in her mouth. I remember the face-off (nineteen years ago) as if it were yesterday: Rottweiler jaws clamped tight, dribbles of pink bubbles sliding down the chin and dripping to the ground. A stalemate. It is hysterically funny in retrospect, but at the time I was just hysterically terrified.

I knew Sasha loved me, but would she bite me instinctively, protecting her precious Brillo pad? It was certainly within the realm of possibility.

As we raised our three kids – and several of our friends’ kids, too – into a household of dogs, we taught them to have a healthy respect for all animals, no matter how domesticated. My kids (and my husband) never met a dog that was a stranger, so we taught them to control their impulsivity quite directly:

•    approach new dogs cautiously,
•    ask permission of their owners, and
•    hold out the backs of their hands to be sniffed

If I could be afraid of my dear Sasha, then anything was possible. My kids learned to proceed with caution before playfulness - not an easy task for a passel of kids with ADHD! It’s worth noting here that my friendly, playful spouse had learned that lesson the hard way. In fact, you might say a big black chow had to bite him in the butt to teach him how to teach his kids to manage their impulsivity.

Comfort and companionship (and energy release)

True confession: Sometimes I get jealous of my dog. My kids talk to her and feed her. My husband plays with her on the floor. She gets the attention from those I love that I wish I got more often. And I wouldn’t have it any other way.

There is a pure and healing energy that a well-loved animal brings into a home, sometimes coupled with a release for unbridled hyperactivity. Talk about a perfect recipe for ADHD success!

Pets invite us to take some time each day to relax and play. They offer friendship and companionship. They ask very little in return, except that we make the time to be with them, to be kind and playful, and to take care of their basic needs.

Pets teach us to:
•    slow down
•    pay attention to the fundamentals
•    be kind
•    enjoy life
Are there any more important lessons than those?

As an added benefit, some pets offer a physical outlet for excess energy. A great dog is willing to run, wrestle, and roll around on the ground with the kids, and becomes a walking buddy and accountability partner for parents. In an ideal world, that dog is also willing to sit quietly at your feet as you do your homework. That kind of friendship can be hard to find.

A special treat

Recently I had a discussion with my son about a structure for making sure the dog is fed. Since he was starting to feel a little “wrong,” I stopped the conversation to assure him that he’s doing a great job. I explained that it’s important to find structures that work for him, because we’re not always going to be around. To be successful, he’s going to have to learn to use systems to get done what he wants to get done. It was a great teachable moment.

And then I had an aha! moment: Feeding the dog is one of the hardest tasks I could give to a child with ADHD. I’m always talking about improvement instead of perfection, but feeding an animal is one situation where perfection is actually important. A 90% isn’t good enough. When I told my son that, he responded,“Yeah, mom, but I can get points for extra credit. I can give her treats!”

Animals change the playing field when you have kids in your home. Having a pet invites children to learn to communicate on another plane. It’s one of those little gifts of life that is difficult to express. You can't overestimate the peace and joy it can bring.

A longer version of this post appeared in the April 2013 issue of Attention magazine. Join CHADD and receive every issue!
Join conversations about parenting kids with ADHD on Attention connection, your social network for all things ADHD!

A member of CHADD's board of directors, Elaine Taylor-Klaus is a certified coach, parent coach, writer, educator, speaker, entrepreneur, and mother. She is the co-founder of ImpactADHD.com.